Chapters Transcript Postpartum Mental Health and the Parent-Child Dyad Bridget Galati, DO, presents several cases on maternal mortality and the maternal health access project. Well, good morning, everyone. Thank you for joining us for Early Bird rounds today. Uh, before we get started, I wanted to give a special shout out to Paula Murphy, as today is her last day with BJC. Um, Paula, we've really enjoyed working with you and we hope that you enjoy, um, this next chapter in life. Um, so before we get started, we also have a few more new announcements. Um, we will be sending a survey out to you for an evaluation for early bird rounds each week. If you would please take a moment to give us feedback so that we can continue to improve this virtual conference, um, and you'll receive that through a link. Or you'll receive that through an email with the presentation slides today. Then the usual announcements so just please keep your cameras turned off and your mics muted during the session, um, and If you do have any questions, there will be time at the end for that as well as scanning the QR code. I'll put that back up as well. Today, we have Doctor Kelli Bishop. And she is specialized in psychiatry, and today she will be speaking on the topic of eating disorders, diagnosis, and treatment. And I'm getting her slides pulled up right now and as soon as we have those, we'll turn it over to her. OK. Hopefully everyone can hear me all right. Madison, things still seem like they're working OK? Yes, everything is great. Awesome. All right, well, thanks for having me. I'm excited to be here to talk to everyone. Um, again, I'm Kelly Bishop. I'm at the psychiatry department here at Washington University. Um, I did all my training here and then I left for a couple years to work, um, an eating disorder, a residential, PHP IOP program. Um, and then I I was brought back to try to expand, um, psychiatric care for eating disorders. So that's why I'm talking to you today. Um, kind of a little go over kind of where we are in the diagnosis, treatment of eating disorders, and a little bit about what kind of the new clinic that we're trying to build and um see how we can be helpful, um, treating this patient population. So, I've no disclosures. Um, like I said, you know, we'll kind of talk about a little bit just general like why we care about eating disorders, what are the diagnoses, how do we go about diagnosis diagnosis this, um, what are the different psychiatric complexities, how a psychiatrist can be helpful, and then more about um the new clinic that we're working on. Um, so, to start off, right, why do we care? Well, unfortunately, eating disorders are prevalent, they're deadly, um, so about 9% of the US population will have an eating disorder in their lifetime. Um, they are, like I said, deadly. I'll talk about that a little bit more in a second. And then, um, eating disorders really do affect everyone. I wanted to kind of point this out a little bit more. It's been not that uncommon where I've heard eating disorders, especially like anorexia referred to as the rich white girl's illness. It is not true. Um, it can affect all ages, starting as young. On this slide, it says 5, but kind of in my RFI clinic, I'm, I don't know, I saw a 2 year old the other day that, um, definitely is meeting criteria, and then, you know, patients, you know, they can eating disorders can still happen, um, in older age. Right, it can affect all races. The unfortunate aspect, though, is like a lot of health care in the US, people of color with eating disorders are half as likely to be diagnosed or to receive treatment, right? It can affect all genders. Yes, females are still more common to have them, but, um, we won't forget about the men in this situation, and then, right, it can affect all sexual orientations. Um, it's a little bit more on the mortality rate, so it's very deadly. Um, it's a 10% mortality rate, especially from like the anorexic side, um, decreases, um, life expectancy by 10 to 20 years, and, um, Eating disorders compete with substance abuse for the highest mortality risk of psychiatric diagnosis. So they're serious, we want to catch them, we wanna treat them. And then, you know, unfortunately, they're they're on the rise. So, you know, we've eating has always been around for, you know, generations, centuries, um, so they've always been there, but um we do have been seeing an increase in them. So this graph here shows kind of um eating disorder. A number of visits to emergency departments. Um, so, right, they're always coming in, it was always a problem, but then, right, we had COVID, which is that dotted line, and then we saw a huge uptick. So, you know, they're still higher than they've been, um, and there's still um a serious concern. You know, a lot of people ask like, well, you know, what was it with COVID? We're still kind of speculating on that, but kind of the best explanations we have for now is one, well, COVID was traumatic, right? People were isolated, people are looking for new ways to cope, to feel in control of their life. So some of the restricted eating disorders really kind of played into that and then some of the more um Loss of controlled eating disorders, maybe kind of fell into that play of just people feeling more out of control, having a hard time controlling their lives, and then turning to eating, under controlled eating as kind of a coping skill. The other component too is that Um, right, people were all kind of stuffed in a house together. Um parents and maybe, you know, other adults were having a closer eye on maybe their children. So, right, a lot of mental health issues got worse, so people were more aware of that and probably also just noticing some of these behaviors that people were engaging in. It wasn't as easy to hide. So I think there was one that, yes, COVID in and of itself kind of increased these behaviors, but also I think we were catching them and more aware of them. So, right, they're on the rise. How are we doing at catching them now? Uh, not great, not as well as we like. So, um, here's some information about the average number of months it takes from onset of symptoms to when someone actually gets diagnosed and starts treatment. So for anorexia, it's about 30 months, bulimia 53 months, binge eating 67, ASE average of 43, so it's other specified feeding eating disorder. Um, and then RFed, right, avoidant restrictive food intake disorder, that's 35 months. So we still have some work to do. So thinking of that, it's like you, where do we start? What do we start looking for? Can we catch things earlier? Um, well, you know, one of the red flags is it often starts with disordered eating. This term is most commonly referred to and kind of started off being referred to in the context of more restricted eating disorders like anorexia nervosa, um, and kind of the general definition, be something along the lines of like, it's a problematic eating pattern. And behavior due to distorted views surrounding food or body image. So, um, you know, kind of an example of this is you kind of a young kid, a young adolescent who's getting interested in diet culture, thinks it's kind of cool to start really obsessing about, you know, well, if I eat this and this, what is it going to do to my body? It's not to the point of it becoming a disorder, but it's definitely becoming more of an obsession or something they're really overly prioritizing. I'm starting to kind of expand this definition though within my own clinic, cause right, you know, there's far more eating disorders than the ones that are more fixated on body image or, you know, only restriction. So what I'm kind of more so using it as when I talk about disordered eating is that it is suboptimal eating patterns and behaviors that a negative association with food, right, because we have RFID, we have binge eating disorder. So it's starting to see these patterns of using food and starting to use it in an unsustainable way as we want to kind of start as best we can screening for that, getting an idea what someone's relationship with food is to hopefully start catching these behaviors before it becomes a full disorder. So then, right, when do we call something a disorder? Well, in psychiatry, kind of the rough term is like, when is it causing significant impairment in someone's life. So the definition specifically for like eating disorders is eating behaviors um that negatively impact your health, your emotions, your ability to function in important areas of life. So it's, it's keeping you from doing things that you want to do, um, and it's causing, like I said, significant impairment. Um, so, I know you're all trained pediatricians, um, and I do what all the diagnoses are, but we'll kind of just review them, um, make sure we're all on the same page, especially, especially with our fed I'll talk a little bit more since I know that's newer, and I think we're starting to see it quite a bit more. Um, but to start off, the one that most people think of when we say eating disorder is anorexia nervosa. Um, the main criteria for this is that someone has food restriction, um, caloric restriction that leads to malnourishment. And the reason that they're engaging in these behaviors to the point of making themselves malnourished is that they have intense fear of gaining weight, um, due to a disturbance of body image. So they just never think they're good enough to think if I can be smaller, if I can be thinner, I can be better at X, Y, and Z, people are going to like me better, and then they engage in food restriction, um, and or exercise. So basically coming up with a significant caloric deficit where um they're no longer giving themselves enough nutrition. Um, there are two subtypes of this, um, which a lot of like patients aren't aware of. So, right, there's the restricting subtype, which is what, um, I kind of just went over, so it's really, um, the main behavior is restricting calories coming out with that net negative, that could be through either food restriction and or exercise. And then we have the binge purge subtype, um. So really, what that looks like it's, most patients engage everything in the restricting subtype, but then they also engage in either or binge and or purge behaviors. Um, a lot of people get confused like, well, why would someone who wants to lose weight, why are they engaging and binging? Well, it's pretty much right. They're starving themselves for so many days, they're hungry. They then um feel that loss of control, engage in a binge, but then, you know, they go back and have poor compensatory behaviors, so, you know, restriction or then engage in purging to still end up, you know, net negative. And then purging just as a reminder, right, it could be at either end. So if someone's taking laxatives, diuretics, it's still getting rid of nutrition throughout, um, you know, expelling it one way or another. And then we have limia nervosa. So to have limia nervosa, someone has to be engaging in binge eating, um. The DSM has this, like, really vague explanation of binge eating, where it's like eating more than the average person would eat in one sitting. You know, what does that what does that mean for each person person? Um, what I typically kind of explain is that it's eating, for the most part, like, your caloric need for the day in one sitting. Um, the thing though that makes it then not binge eating disorder, but bulimia nervosa is that then they have recurrent inappropriate compensatory behaviors to prevent weight gain. So then after a binge, people are then, you know, purging or fasting, using medications to lose weight, you know, doing things that are not safe for the body to try to counteract the binge episodes. And they have poor body image because of this. That's why they're really engaging in these poor compensatory behaviors. Um, the big difference between bulimia and anorexia is that though the patient is not malnourished, there is, you know, the, the binge eating or the other types of nutrition that they're getting is offsetting the inappropriate compensatory behaviors, so they're not ending up with that, you know, net negative. Granted, it's still very dangerous, you know, going from, you know, the body, it's very stressful to, um, intake that much nutrition and then maybe go some time without eating, especially in the context of purging, you know, that can be very dangerous. So I try to, you know, educate patients and parents where it's like this still is serious. This isn't something that, you know, We can kind of just ignore. Like, this is still very serious, people end up in the hospital because of bulimia. Um, and then we have binge eating disorder. So it's again, uh your current episodes of binging, like I mentioned, um, so eating a large amount, which is typically about, you know, at least the caloric need for the day around that in one sitting, which is about a 2 hour window is the general criteria. But the thing that makes it then the disorder is that this is very distressing for patients. It's not necessarily what you would consider like just overeating. They sit down, you know, they maybe they're hungry and they start engaging in eating, but then they get completely, they feel out of control, they're eating past fullness, they want to stop, but they feel like they can't, they feel embarrassed, they feel guilty and disgusted about this. So it's, it's very distressing um for parents, uh, patients with these episodes. And then we have ARFID, so right, avoidant restrictive food intake disorder. Um, there's kind of two main criteria to be diagnosed with RFID. The first one is kind of separated into different subtypes, um. So the first one I have listed here is what we call the avoidant or the sensory subtype, kind of just depends on which paper you're reading, which one they use, and that is um dislike of sensory characteristics of food, which then leads to a feeding or eating disturbance. So that's really, um, you know, patients who are avoiding eating because they don't like the taste, they don't like the texture, they think it looks gross, they're really picky about color, the smell. The next subtype then is um the aversive subtype, which is concern about aversive consequences of eating. Um, so this is worried that, you know, something bad's going to happen if I ingest this food or any food or a certain type of food doesn't matter, but it's then causing a significant disturbance in eating. I think maybe a common story that we probably all seen at some point is maybe you have this anxious kid who had an actual choking event or maybe was worried about choking, started limiting some foods where they felt the sensitivity. Um, and then they just started limiting more and more and more. Or you know, the kid who has maybe some, you know, IBS or uh visceral hypersensitivity, and they start associating that distress with food, so they limit more and more and more. And then the last subtype here is the restrictive subtype. It's a lack of interest in eating, um. So you don't see as much, but it's definitely out there where there's just some patients that just are kind of less motivated by food, aren't very interested. So over time it just gets harder to keep up with the nutritional requirements. They get busy, especially I see usually manifest more like when people get busy in like high school, college, where they're just like, I don't know, I just forget to eat. And then, you know, as their stomach essentially becomes deconditioned, not seeing food consistently, when they start wanting to engage and better eating habits, it's distressing, it's uncomfortable. They're not used to feeling full, they're not used to eating enough, um, and they feel like something bad's happening because their body hasn't had those sensations or felt hunger in quite a while. Um, to have though, the actual RFID diagnosis, you have to then have one of those other second criteria. Um, and that would be significant weight loss is one. We could have, you know, significant nutritional deficiency due to the behaviors that I talked about above. It can lead to dependence on supplements or internal feeding, um, or it can be interference with social functioning. And how I kind of describe that one is that it's basically Is the behaviors that they're engaging in to to to try to stay nourished, right? Maybe they're not having significant weight loss, but what behaviors they're engaging in is make it really hard to live their life. You know, I have one young patient who is like, I can't eat in front of anyone. I'm avoiding going out to friends. I don't know how to go to prom. I want to ask this girl out, but I Can't take her out on a date. Like, he's like, I, I, this food is like controlling my life because I can't share it with people and food is social. So, you know, I, I'm comfortable diagnosing with RFID because like, yeah, that is a huge interference with your social functioning. There's also a component too of like, you know, maybe they're not malnourished, but the things that parents are doing to keep the kid nourished are just, um, so kind of far out there. And if parents weren't able to do that, they would end up malnourished. So that's kind of how I think about it, kind of the stress on the patient, but also the parents, and what are they doing to keep up with this. Um, the one thing I want to point out that for as far as the three different subtypes, you know, we kind of do diagnose one versus the other, but that's not to say that they don't travel together. Um, but we usually see one primary and then maybe there's like, uh, a spritz of kind of the other um subtypes in there. So they don't necessarily travel alone, um, but we try to diagnose one versus the other cause treatment and type of therapy you do does vary, and I'll talk about that a little later. Um, one thing I'm gonna throw in here too is that um, There's kind of a new term coming up called ARFID plus. Um, it's not in the DSM, but really what it means is that someone starts off with ARFID, any, any sort of like the subtypes that I just talked about. But then over time, especially as they become very malnourished, um, they develop then anorexic traits of, OK, now I'm actually in a really double down on my RFID behaviors because I actually want to lose weight because I like being, you know, skinny or small, um, and I, I am doing this because of poor body image. You know, we don't know for sure what this, why this phenomenon is happening. Um, and that's why it's, you know, it's kind of a newer term, but they call it RFID plus. You know, one thought is, you know, is RFID, can it be a precursor to anorexia? Um, it can be. Sometimes I've seen it happen, but for the most part, they can be pretty separate entities. Um, the one thing phenomenon that we do also see was, um, what was Kind of demonstrated in the very controversial, um, I don't know if controversial, just frankly, probably unethical, Minnesota starvation experiment that was done around the 1940s, I think, um, where they took, I think it was like 30 healthy, willing participants, and they basically starved them. Um, and what happened was there was a subset of these men that once they became malnourished, they developed anorexic thinking, and then it was hard for them to weight restore because um there was some odd, um, change in, um, thinking of that, like, no, this is, this is better for me to stay skinny. I don't want to gain the weight back. Um, however, you know, there was a subset though that didn't. Prove they were restored, but a subset that did improve once they were weight restored. And I have seen this in my own like RFID plus situations where once we get the patient nourished, that anorexic thinking tends to diminish or totally go away, and then, you know, you're still left with the RFID, but it's a little less complicated. So working to get these patients' weight restored is kind of the main first thing to start them off with and the main treatment. Um, and then we have um other specified feeding and eating disorder, so Ausfed, um, because that's easier to say. It's really, you know, um, When someone doesn't fit perfectly into our little DSM boxes, we still have a diagnosis that we can code for, bill for, um, to get and then get patients the treatment that they need. So it's like, you know, they don't fit perfectly into the puzzle, but, you know, do they definitely have an eating disorder? Yes. Do they perfectly fit these categories? No. But do they need treatment? Yes. Um, so for the most part, if I'm diagnosing ASFed, um, it's probably in the context of RFID Plus, it just, you can't bill for that. Um, So we kind of know, we went over the diagnoses, um, you know, a lot of people are familiar with them, aware of them, but why is it so hard then to, to catch them, to treat them? Why is the, the amount of time from the illness starting to diagnosis and treatment, um, why is it taking so long? Well, part of it, right, it can be difficult to, to uncover. Patients aren't coming to us saying, Hey, I have an eating disorder. Please treat it. Um, so kind of break down by diagnosis kind of some of the things psychologically that are going on that I think make it harder for patients to come in with a chief complaint that makes us think eating disorder or makes it harder for us to kind of uncover is one, for as far as the anorexia population, they don't really want to be found. Anorexia is what we call ego syntonic, so unfortunately it feels good in the moment. These people feel like they're in control. They feel like they're doing something good to their body. They feel like they're winning something. So you know they're constantly trying to hide these behaviors. They don't want treatment. You know, it's like things that I tell parents where it's a pretty common story where they're like, you know, I just thought, you know, my kid was getting older, their body was changing, and then, you know, they kind of changed their style. I thought the baggy clothes was just, you know, what the kids wore now and really the patient was wearing significantly baggy clothes to hide the change of their body so they didn't get caught. That's just one of the many examples of things that is that these patients do to try to hide what's happening. Um, and then for bulimia and binge eating, I find a lot of these patients, it's a little hard to. To kind of engage them in some of the conversations and talk about behaviors because they feel um shameful about it. So sometimes they really avoid in these conversations. I had quite a few patients who engage in binge eating that takes quite a few appointments for them to actually talk to me about a binge episode. So it's, you know, giving them the time, um, and the space, but also, right, not just kind of they say no and just checking it off. And then for Red, I mean, it, it's, it's kind of confusing, right? There's all these different subtypes, um. And these patients, you know, coming in with usually a bunch of different complaints, and um it's, it's newer, so we're all trying to learn about it, and a lot of parents and patients haven't heard about it, so that, that can be hard to kind of pinpoint in an appointment. So think about that, you know, what's What do we usually see when these patients come in? What is maybe kind of delaying the diagnosis to an eating disorder? Well, you know, patients come in and they usually are complaining about GI complaints. Um, and that's usually what we see first. Um, and then these GI complaints for the most part are usually end up falling into the category of, um, functional abdominal pain, uh, which is now called disorder of gut brain interaction, which I'll now say DGBI because that's a less of a mouthful, but that's the same thing as functional abdominal pain. But as we all know, we love to change what we call things to. I don't know. So important still. Um, so, so I'm gonna talk a little bit more about kind of the crossover between like a functional abdominal pain, DGBI, um, and eating disorders. So we can hopefully try to catch these things sooner. So DGBIs and eating disorders go hand in hand. Um, this one study here basically shows that, um, most patients with eating disorders had at least one. Um, DGBI diagnosis, and then, um, even, you know, then there was still a subset of a large percentage that even had, um, 3 or more DGBI essentially like diagnosis or criteria for it. So this graph really just shows here that the dark blue is that the more severe the eating disorder, the more DGBI or functional abdominal complaints that they had. Um, so eating disorders, again, DGBIs, that should be kind of a red flag, um, thinking about If it's kind of coming up with these big abdominal complaints, not quite sure what's going on, really making sure we think about a screening for eating disorders because I think we, we all know like how these patients can go from provider to provider, specialist to specialist before we kind of realize, all right, there's really probably nothing clearly anatomical going on. And if we could skip some of those um those tests and get them, you know, the sort of treatment that they need, that would obviously be beneficial. I want to talk a little bit more about RFID and DGBI specifically because there's a lot of overlap there. Um, there can be a lot of similarities, um, you know, some people out there are like, are they actually different? Are they not different? Does it matter? Um, there's kind of one graph out there that's, you know, thinks about this, one paper kind of talked about it, they're like, right, is DGBI and RFI just the same thing? Do you just get unlucky and you have a DGBI and you have RFID, or do you have a DGBI and then it bleeds in and becomes RFed, um. At the end of the day, kind of, you know, in my own experience and kind of going through the literature, I think it is important to differentiate the two, because RFID at the end of the day you get that diagnosis because it's mainly associated with like eating and weight related complaints. So once it becomes a problem when these patients are no longer engaging in appropriate nutrition, um, you know, they get the diagnosis of ARFID, and that can have a pretty significant change in how you want to progress with treatment, what kind of treatment you're going to seek. Um, some other things to think about, so stomach complaints are a pretty big predictor. If it's RFID versus lower GI complaints tend to not be as associated with an ARFID diagnosis. Um, ARFID though tends to be under diagnosed. Usually when someone gets a diagnosis of DGBI, they kind of stay with that, go on that treatment, but ARFID doesn't usually get attached on, even if they haven't. So there's one study that out of 410 charts of patients who've had a DGBI only one was formally diagnosed with RFID, but when they went back and looked, um, 6% met full criteria for RFID, and then there was another 17% that likely had a diagnosis of RFID, but just wasn't fully fleshed out yet. This is my own kind of a way that I think about RFID and DGBI how I kind of um formulate my cases. So, you know, the most crossover that I see between the DGBI population and then the patients that have RFIT are really with a versus subtype, right? So the versus subtype again is when like, I am afraid to eat because of a bad consequence, which is often a GI consequence. Um, you know, did that start out with more of like, hey, we had a choking episode and now the patient is like avoiding, avoiding. Avoiding, and then they avoid it so much. Now, anytime they feel any sensation in their throat or like really notice anything swallowing, they think something terrible is happening and then parents kind of didn't put the whole thing together. And now they think, oh, there's actually something wrong with their GI tract. So they get funneled into like the DGBI category, realizing the exciting event had really nothing to do with that. Um, or, right, the other thing, the other, um, The alternate thing is it starts as a DGBI where, right, this kid has IBS or they have like visceral hypersensitivity, or, you know, they're an anxious kid and we know anxiety and GI tract distress goes hand in hand, and then, you know, they kind of realize, OK, well, if I don't eat these foods, I feel a little better, they avoid, void void to the point where, right, they're not eating enough, maybe become malnourished, then you really bleed into that RA diagnosis. Um, not as much crossover with the avoidant and restrictive subtype because they really have a very different onset of symptoms than like a DGBI. However, it can then lead to getting that diagnosis of the DGBI. So, Avoidant is someone who is Um, not eating because they don't like texture, tastes, the sensation of food, um, and the restrictive subtype where people just start eating cause they're just not really into it. Um, but right as we know, over time, the more you avoid food, the more you're limiting when you start to then expand or especially if you need to wait restore, it's uncomfortable. It feels bad. People think that there's something then wrong with them. So they don't, you know, a lot of patients don't put together. Parents don't always put together where it's like, no, they're uncomfortable because they actually just need to eat, and that's a natural process versus like, no, you need to fix this discomfort so they can eat again. So kind of thinking about it and that breakdown to kind of pinpoint like where did things start can really help kind of formulate the problem for the patient and the parents and then get them the right type of, um, of treatments. And we'll talk about treatments later on too. So, you know, now that hopefully we have a little bit better idea of like, why it's hard to diagnose, what are some of the complexities. It's like, what, what can we do? What can we kind of start adding to our practice? You know, the first thing is making sure we always, always ask, um, you know, I remember being a young psychiatri intern, and like, I don't think I almost ever asked anyone for eating disorder. It just wasn't really ingrained in the practice yet. Um, obviously got better over time because I'm eating disorder psychiatrist. I will say was you in general though throughout training does a good job because they do actually have specific eating disorder rotations for their psychiatrists. That is not the norm though. Most, um, psychiatry residencies and fellowships, depending on the subspecialty, um, don't get specific eating disorder training, and I imagine, you know, that might have some context, right, also for other residencies and specialties. So a lot of people just don't even know like how do you include this into Um, your visits, so thinking about what would work for your practice, how, you know, to work in these screeners. Um, and at the same time too, sometimes these questions are hard to ask. So in some ways I try to kind of initiate it, um, that seems a little less awkward than just being like, hey, do you have an eating disorder? It's like, you know, can you describe your relationship with food to me, or especially if I'm screening for anxiety, depression, and I'll say something along the lines of, you know, a lot of times people are being anxious or down, it changes the way they look at food. Has that happened for you? Um, you know, how often do you think about food during the day? Um, asking generally, you know, like, are you happy with your body? Are you happy with how it feels? Do you think it's doing what it needs to do? Are you happy with how it looks? Um, you know, does eating make you nervous? And then like for a parent, kind of a good segue is kind of also like, you know, is mealtime stressful? Is it, is it hard to feed your child? Um, again, everyone kind of has their own style, but this is kind of some things that I use when it's like, you know, starting to break that ice of how to even bring up these hard conversations. Um, the other thing is, right, looking at growth charts. Now, um, I know I'm talking to a bunch of pediatricians, I'm showing you a growth chart. It's not to be insulting, but it's just as as reminders, we always need reminders is, you know, sometimes you have a sense of what's going on and, you know, patients being really kind of um evasive and maybe parents are not super present present. Looking at the growth chart um over time can really help get an idea of like, OK, no, like something is really happening, we have to intervene. Um, so, you know, a very common one for like the restricted eating disorder, right? You have that nice map of the child's growth, and then, right, you just see a a steep drop off. Um, and then once you kind of piece things together, we start seeing this, right, when they start saying, well, yeah, you know, I cut out fat because it's not good, and then you processed food, and then that became really all carbs. Um, so piecing that together, and also, like, this is really helpful to all oftentimes show parents too, um, especially for parents that Maybe are in disbelief, you know, it's scary to have a diagnosis of an eating disorder, but to kind of show them, like, hey, this is the map of your child. Um, I know a lot of parents, especially parents who maybe are have anorexia or eating disorder themselves, or at the very least, like that orthorexia category, um, you know, sometimes it's like, well, you know, they just, they're an athlete, they're just working out more, it's fine. But then, like, when you show them the chart being like, hey, like, this isn't this chart isn't to compare them to other kids. This is just a graph that we have. To map your child's growth, and this is your child's map, they were growing, and now, and now this is what's happening. Like, let's let's figure this out and do something so we don't risk, um, you know, their bones not developing appropriate, their brain organs, those types of things. And then right for um a height, you know, if there is some height um stunting that's helpful to also show um families. So usually what we see right is like they're growing, doing well, and they kind of have this weird plateau, um, which would be abnormal for the age that they're at. And then again, it usually correlates right when their weight started dropping. So that's also helpful to point out to parents when they're very much in disbelief of like, well, no, they just, they slimmed out. That's really healthy for them. It's like, well, they actually stopped growing too. Um, I very rarely show the patient, like especially the child, these graphs because there's numbers on them, you know, a lot of people are naturally 80th percentile or above, but no one wants to see that number with society. But so what I'll often do is I'll just draw them a standalone curve and just be like this. was your curve. I mean this is your natural body's growth. And then, right? 00, you know, the body image kicked in, eating disorder told you to stop doing these things, and then, and then you stopped growing. They'll kind of show just a decline. And sometimes it's help for them to, you know, understand like, OK, there is actually something negative that's happening. And then lastly, you know, BMI, um, I guess if they're out there, um, there used to be like specific BMI requirements like anorexia. They're only now considered, um, Ways to classify severity, so you don't have to have a BMI cut off to have anorexia. Um, I think, you know, if it's 18 above the BMI, it's considered mild, but that means you can still have anorexia. So I mean, I've diagnosed plenty of patients who maybe they had a actual BMI of, I don't know, 26, and then they dropped to 21. Yes, they're still in a normal BMI, but that's like, right, that's a huge percentage loss of body mass that is not, not OK for that growing kid. So, you know, again, just to look at it again, someone's BMI maybe it started off, you know, higher, but that was their own body's natural growth trajectory, and then they dropped off. So I have seen um providers of all subspecialties get um Kind of not confused, but just, you know, going through things quickly and see like, oh hey, your BMI 75% or 75 percentile. Great, except, you know, for getting to look at the whole overall picture being like, oh, but you were higher than that for like your whole life. And like, I know this family. I know that they were, you know, eating appropriately, still active. This is just their body type, and then realizing, you know, that's still like that's a significant drop off. So kind of making sure everyone remembers to look at the whole picture and then also show the parents the whole picture because parents feel like they're 75% be mind, what is your problem or percentile. Um, but showing them the map of the child's growth can be really helpful. Um, there's also screeners that are available, right? Sometimes it's hard to have these conversations, or at least know who do we start this out with. So if giving someone a screener or sometimes, you know, someone like doesn't want to talk about an appointment, it's like, you know, go home, fill this out, think about it, bring it back, sometimes that's helpful. There's not like one great uh screener that covers everything, at least one that I haven't found yet. Um, just kind of a breakdown by diagnosis of ones that I tend to use. If anyone has any better suggestions, let me know. Um, but for RFed, there's the 9 item RFID screen, there's a parent and child version, which is helpful because RFID, right, can affect some really young kids. It's insufficient for differentiating between RFID and another eating disorder. So, like, patients with other types of restricted eating disorders are gonna um still screen positive on this because they're gonna have a lot of food avoidance, but for other reasons. So like, if you suspect AFI and only RFID giving this might be helpful, but if you're screening in general for just all eating disorders, I would combine the nice screen with like um the eating disorder exam questionnaires, the short version, because then that breaks out um anorexia bulimia and binge eating. Um, that one's geared more towards, um, like adolescents and older kids and adults, um, just because of the language it uses. So there is an EDEQ which is, um, Uh, a use questionnaire, so it's a little bit easier um for younger kids to answer. But of course, that one doesn't include questions for binge eating, um, so you can combine it with the bed seven. so this is kind of like the different ones that I tend to use and combine them but based on what I'm looking for. So to make things more complicated, um, eating disorders don't travel alone. Um, about 70% of patients with eating disorders also have something else psychiatric going on. Which, you know, can complicate treatment and that, you know, we're trying to deal with more than one thing at once, and, you know, these patients typically have, you know, other types of struggles which makes um dealing with eating disorder difficult. So to kind of look at, you know, a breakdown of what that looks like, you know, one, this, this study, this graph just shows that, yes, all most eating disorder patients also have a comorbid psychiatric diagnosis. Um, there is some variation between the diagnoses though. So I think the way, what I would point out here is that patients with bulimia nervosa, binge eating disorder tend to have a higher rate of kind of anxiety, mood disorders, but also like impulse control disorders. So, um, that would be ADHD if you kind of think about that. And patients who have ADHD, especially under controlled ADHD, are having a hard time with impulsivity, and there's a very impulsive component to binging. So making sure ADHD is treated, that you're looking at that, because that's going to help with the patients using those coping skills to not engage in that very kind of impulsive behavior. Um, and then to look at RF and more specifically. Um, They kind of break it down by the different subtypes, but overall kind of the combined one is helpful to look at. You know, the big one here is that anxiety is a big player um for patients who have RFID, um, which does make sense, especially that aversive subtype. And the other one is that, um, autism can be pretty common, um, you know, with kids with RFID, and then, um, also kind of like learning disabilities also to break that down then a little bit more, um. The most common um subtype that has anxiety, like I mentioned before in RFID, is that aversive subtype. Something else I want to throw out there to them is that I've kind of, um, started to realize with the aversive subtype that a lot of these patients end up with a diagnosis of PTSD, that it's what happened to them for them to start avoiding food is actually really traumatic. Um, so like the patients who did have a pretty traumatic choking episode and then like a scary hospitalization, or I had one patient who had a really terrible, um, Complications from medicine that they were on and ended up with terrible colitis, really scary hospital, hospital stay that ended up meeting criteria for PTSD then that led right to an or diagnosis. So kind of thinking about that too, um, can be helpful to make sure these kids get the right treatment they need. And then for the avoidant sensory subtype, um, autism is not uncommon for some of these patients to have, which, right, most patients with autism have those sensory sensitivities, um, right, they don't all go on to develop RFID, but it's not uncommon that, you know, when they do, they have some sort of um You know, traits of of autism. And then, you know, again speaking to bunch of pediatricians, we always have to remember to um screen for abuse, um. You know, one that out there is that women who reported childhood physical abuse are at twice the odds of suffering from an eating disorder, and then in my own practice, you know, how I kind of see um abuse then. You know, ending patients who have abuse and ending up with an eating disorder, you kind of break that down by diagnosis again. So for patients who develop anorexia, it's kind of in the context of, you know, I have this very um Scary, you know, life that I'm living, and I, I don't feel like I have any control. Well, I can at least control what I'm putting in my body. I can at least control what I look like. For like the binge eating, um, disorders, I see that um a lot of times in patients who had a history of food insecurity, um, right, so they ate as much as they could, um, but then, right, those behaviors didn't didn't get better over time. And then I mentioned again with RFID, right, some of the avoidance of food was due to a real negative association, so I had had some sad cases of kids who were really violently force fed when they were younger, and then developed that aversion that led to AFI. So keeping that in mind, um, as we always, always do. And then, to talk more about treatment. So, um, the overall kind of model for eating disorder treatment is this five-step care. So in the pyramid, um, top down is decreased acuity. So when patients are really medically unstable, you know, typically they're very malnourished to the point of vital change, lab changes, or you know, are they purging to the extent of, you know, um, other, you know, Vitals, lab changes, or, you know, structural damage. So that's inpatient treatment that's needed. Um, after inpatient treatment, this step down then is to residential, where patients still need 24/7 care for them to not engage in behaviors, and then also make sure that they're engaging in the meal plan. After that, we have partial hospitalization, which that's basically someone's there for 5 to 7 days a week, somewhere between like 6 to 10 hours, depending on the program. Um, that can be helpful in that they still are eating like a lot of the nutrition that they need, getting a lot of the help that they need during the day, but then still having that exposure outside of treatment. Um, and then you then move down into the outpatient world, so you have intensive outpatient, which is a couple days a week for a couple hours to get, you know, more check-ins usually with like a dietitian, therapist, and having some groups to connect with others. And then you have the classic outpatient model where you see your, your team. About, you know, once a month, maybe once every other week, depending on the provider. So what I mean by outpatient team, um, you know, typically the best model we have is to have a multidisciplinary team, as I hopefully got across, in disorders are complicated. There's a lot of moving pieces. So a typical team is, um, The physicians, um, whether they're right, the patient needs a psychiatrist, you know, working with a pediatrician, do they need a GI specialist and also help if there is kind of an underlying GI illness, um, to have the mapped team, and then you have your therapist that can be both um psychological therapists, but also right, we have our occupational therapist, speech therapists that can be really Helpful in some of these RFID cases. And then, um, a dietician to really help make sure that the meal plan that we're starting with these kids, um, are meeting all the requirements. Dieticians can also be pretty helpful with kind of tricky things like food chaining, um, for the AA kids of like how do we start slowly incorporating other foods. And, um, you know, what combination of providers someone needs, it really depends on the diagnosis, um, but as we all know, treating these are hard and no one likes to do it on an island, so the more people we can get on board is best for us both to prevent like provider burnout, and then also make sure these kids are getting what they need. Um, Then there's like, just I want to talk a little bit more about what psychotherapy looks like, um, and just point out again, so FBT family-based therapy, um, is still considered the gold standard outpatient treatment for anorexia, um. And just to kind of give a kind of a general summary what FBT is, people are aware if you aren't already. It's really um the modality that empowers parents to take control again over their children's eating, you know, for the most part, um, right, this parent has probably successfully fed their child for years, they've kept them alive, they know what to do, and then the eating disorder sets in, the parent gets scared, they don't. know what's right, what's wrong? What can they do, what they can't do. And they kind of take this back stance, and then, you know, the kids gets worse, and then they come to the doctor, um, they're like, Well, what do I do? But at the end of the day, it's like, well, you're with your child still the most. Like, let's give you, um, You know, the confidence back to know that you can still feed your child, right? You still know what's best for them, and really making the parent again, like the therapist and the dietitian, because they're going to be with them for most of the meals during the day, um, and trying to help give that the the parents the confidence back to do that. Um, I won't go then to all the other types of therapy that we hold our lecture, but, you know, there are different types like CBT. Um, DBT IBT that can be pretty helpful for bulimia and binge eating. There's some evidence for FBT depending on, um, kind of the presentation, but FBT is most evidence-based for, for anorexia and getting a little bit more for ARPA now actually. Which I'll talk about now, so here's my kind of um. Figure here of how I can separate DGBI and RFA and kind of like, wait, how do we think about it? Why do we want to separate it's cause treatment's gonna be a bit different. So for patients who just have a DBI DGBI where maybe it's not bleeding yet into food avoidance, there's gonna be different types of therapy to really focus on like the pain, panic, fear and avoidance. However, when you're getting now into a diagnosis of ARFID where they're not eating to the point of risking like malnutrition, um, you really want to focus on that food exposure. So yes, we still want to work on the pain, panic and fear, but then it's working with the team to really make sure we have the meal plan as the core point of the treatment. And then right using FET empowering the parent to be like, no, like we can do this. Feeding them is not going to hurt them. Let's let's get everyone back on track. So to talk a little more about the parents, right, um, we want to make sure we're also kind of treating the parent almost as a second patient, um, the, the, the joy and the sadness of being in the pediatric field. So, right, um, parents oftentimes, right, they're scared. This is nerve-wracking, like they see their kid getting sick and they, you know, they don't know what to do. And a lot of times, you know, these parents are, are, um, Not hiding this distress from their child. So, you know, a lot of studies are coming out, right? Parental catastrophizing about child pain is obviously possibly associated with the child catastrophizing. So, um, you know, if the parents are upset, worried, scared something bad's gonna happen, that's going to just, you know, make the child engaging in this plan even harder. Um, well, sometimes, so I had this one story of like, um, early in my career, this one patient, um, Had kind of an or picture, but like, had, um, a bad GI bug, vomited, and then became really scared to vomit again, and then had these like panic attacks before eating. Um, but then what happened was when we got them to the hospital and then saw the mom, child of action, was like, the child would be presented with food. You could tell she was anxious and looking at it. You know, maybe breathing a little bit more deeply, and then the mom saw the changes and the mom was like, oh my gosh, oh no, it's happening again. This is, this is terrible. She's gonna, she's going to be scared of vomiting. Oh honey, don't worry, it's OK. We can do this. And then she just had this big emotional response, and then the kids started having a panic attack. So it's right, looking at the whole picture, um, see how can we help the parents stay calm, collected, make sure they're getting the support they need for their own emotional outlet to then, you know, stay calm for the kid. Um, again, I could have a whole another lecture on psychopharmacology, but you know, there are some pretty good medications that we can offer to help these kids, you know, one, to help treat the comorbid, um, psychiatric issues, you know, bad depression, bad anxiety, that's gonna make it hard to engage in these therapies, um, but we do have other medications that could kind of help with like the rigid thinking of some of the eating disorders. Um, so really the slide is just to know that there are options. So just kind of a summary of like what, what we do as psychiatrists in this field, right? So it's helping with diagnosis and eating disorders are a psychiatric diagnosis. There's the psychological component. So helping with that diagnosis, helping with the psycho education, um, you know, we have a bit more time on our appointments to do that than a lot of other providers, that's kind of how we build it. Right? Then can we we can identify the psychiatric morbidities and work on them together? I get this kind of pushback from a lot of patients and parents of like, well, OK, if you fix their anxiety, if you fix the depression, the eating's gonna get better, or the OCD. That'll, you know, fix that, the eating will get better. It's like, well, we got to look at everything together. You know, eating disorder is using everything to its benefit. We have to treat them together. I can't just focus on one versus the other. We got to do it all. Um, so kind of, you know, taking that holistic approach. I mentioned that we have psychopharmacology that we can do. Um, we can help offer refer, um, the appropriate therapy modality, further engage parents, you know, I, we do parent only sessions. I, you know, have sessions where it's like working with the parents that can help with their own distress or getting them to the right providers, and then we do a lot of like behavior planning to engage both patient and parents and like food exposures, especially like for the our population, where we work with diet dietitians and occupational therapists to come up with a pretty behavioral comprehensive plan of what we need to do to get this kid to re-engage. Um, I'll take them maybe, well, OK, we'll do this first, yeah. So, um, yeah, to talk a little bit more about them, the new psychiatry clinic that we're working on. So really, yeah, it's basically um a psychiatry clinic that is mainly trying to offer more comprehensive eating disorder care. Um, full disclosure, it's pretty much just me and our fellows and residents, um, so we're hoping though, um. If we can get as many referrals as we can, um, make sure that there is this population and that we're helpful, we want to continue to, to build it so then hopefully, right, the plan is to hire an, an in-house FBT therapists, get dieticians to really make it um. To, you know, add to the system that we have, you know, adolescent medicine sees a lot of these patients, they do a great job, but we know that's one department, we know psychiatry can be more helpful, so we're trying to work together and especially try to take care of some of these younger kids, um, especially with RFID or even as anorexia is developing before, you know. Third teenager, meet adolescent medicine, and maybe, you know, it was missed for all these years. So, um, the clinic right now, I do see all ages cause I'm embedded both on the child side and the adult side so that if you have any kids aging out, um, I can still see them. Um, so I offer kind of all the psychiatric care that I just mentioned, and, um, you know, well, yes, we treat eating disorders, I'm also happy to see patients that we are concerned about have disordered eating to kind of start figuring out what can we do to catch these patients sooner. Are there certain screeners that can help develop, um, and, you know, or help some sort of, you know, get them engaged in therapy sooner so it doesn't come and develop into a full disorder. Um, so if you think that would be helpful, I'd say just please feel free to refer. I want to be buried in referrals, to be honest, because if we can show you that there is this need, we can help build it out more and help support all the specialties with getting these patients um the care that they need. So you can just send an epic order. It's ambulatory referral to child psychiatry or um to psychiatry if it's an 18 year old, and then, or patients can even just self-refer themselves and making it easy, you know, worst case, I see them, they don't have an eating disorder. I just refer to one of my wonderful colleagues. Easy. We'll take 2 minutes just to kind of talk about, um, you know, sometimes I've heard barriers though, where you tell the parent or the patient like, let's see a psychiatrist, and they're like, whoa, you want me to see a shrink, like, you're, you're missing something. My kid's really sick. This isn't just in their head. Um, so, to kind of help support, you know, that transition. Just to point out, you know, it's like, well, what is scaring these, these parents the most, you know, they're worried about misdiagnosis, they're worried feeling they've been pushed aside or not being taken seriously. So what I find works well it's kind of just reassuring, right? Um. The patient and the parent, like, hey, I'm still here, like, I'm we're not, we're not ignoring the other concerns, but what's going on is complicated, and let's get more help. So, kind of one way to um To think about it is like focus on addition, not subtraction. It's not like, no, I'm not just having you see psychiatrists and then backing off. Like, I will have you see psychiatrists and whoever else we need, right? Your family's going through something really hard, let's get all the help we can get, you know, living, your kids living in pain and, you know, they're, they're scared, that can often lead to declining mental health, right? Let's, let's not miss an opportunity to intervene on that while we also work on the other things, um. One thing that I find it can be really helpful is using that term like individualized plan, like, let's let's get a bunch of, you know, smart heads together so we can come up with a real individualized plan for your kid, right? This is a piece of the puzzle. So trying to talk to to parents of like, this is, this is just something else we're adding. It's not like we're just pushing you into a category, even if it does turn. And to collaborate is kind of the first step. All right, that is the end of my talk. Thank you so much, everyone. I'm happy to take any questions, or if at any point you have questions about the clinic or ways I can help, um, or ways you want me to be more helpful, feel free to send me an epic message or you can email me, um, that is my email there. Thank you so much. Thank you so much, Doctor Bishop. We do have one question in the Q&A box. Um, it should be at the top of your or or at the bottom of your screen depending on what kind of computer you have. It should be next to the chat. Oh, there we go. Um, There's just one in there from today from Kevin Clanton. OK, um, send out in a follow-up email, how to spell each of the eating disorders, screening questionnaires. Yeah, I can do that. Any other questions from anyone? Please feel free to unmute if you'd rather ask your questions that way. Right. Well, I'll assume no questions, um, but thanks to everyone. Um, and again, if there's any follow-up questions, or, oh, the youngest kids that I see, I, I actually don't have a cutoff. Um, I think the, I think the youngest one I have so far is 2 years old. Um, but I mean, I've worked in preschool and toddler clinics, so I'm happy to see anyone, to see if it's, you know, what parent kind of intervention, because at that age, right, there's not any medications, but there's probably a lot of kind of parent-child interaction that I can be helpful with to help parents kind of engage their kid. So, I mean, I'm happy to see anyone. um I'm both adult and child boarded, so just refer away and if I'm helpful, I'm not, I am, and if I'm not, you know, I'll get them to the right provider. Did you see the next question by oh new post, here we go. um. What can we do between office visit and follow up? I guess, like, would you mind clarifying a little more about like between um like your office visit, my office visit? Yeah, it's me. I asked the question. I was wondering, cause sometimes we have a very high suspicion and it may be a month or so before the patient can get in to see somebody. So, I mean, short of, um, doing some labs and EKGs, uh, what, cause you don't wanna confuse the picture by sending them to too many people if they're gonna go to a coordinated plan. So, I mean, do you suggest like weekly visits, every other week? Um, just checking, I mean, is there any guideline on that? I mean, no specific guideline, right, at the end of the day, um, you know, hopefully we can build a more robust. Services, right? So there's not as long of a wait and people can check in. I think at the end of the day, it's kind of deciding, right, do they have a month to wait medically, right? You, you know, something's going on, but right, if labs, EKG, things are looking OK, then it's kind of, you know, make that medical decision. Um, what I usually try to do though, kind of in between um my visit or if like I'm so I'm in the hospital. Um, cause like, like I'm involved in the consult service a little bit, and then maybe a little bit before they see me is like really trying to talk to parents, like, hey, I want you to, to really pay attention to what's going on. I want you to kind of keep your own log of what your kid is eating, making sure they're eating breakfast, lunch, and dinner. Um, and so that When you see the next provider, you have a really good idea of where things are at, because a lot of times parents are like, I don't know. So getting the parent engaged and getting the parent to really pay attention, um, so then, right, if things need to be escalated or they need to come in sooner, um, that can be coordinated more through parent awareness, if that makes sense. That's great. Thank you. And there's 2 more questions in the chat box. Check box. OK. I do not currently have dieticians in my clinic. Um, that is the plan, hopefully over the next year or two. the eating disorder dieticians that we have right now are embedded with an adolescent medicine. Um, so, you know, usually if I, you know, have a 12 year old, sometimes, you know, they, they'll see a little younger based on the need. I'll refer to them for dietitian care and then we kind of co-manage. Um. If it's not insanely, um, medically compromising, I do do some dietitian management myself, um. In the context of, you know, having worked at eating disorder residentials and working on those teams, so if it's not, you know, something that's right there, super like vitamin deficient and eating complex things, there's some aspect of that I can manage, but in general I refer to adolescent medicine or to some community providers that I know that take insurance. And then specific differences between males and females with eating disorders. Um, yes and no. I mean, There's definitely a lot of crossover, right? At the end of the day, um. They meet the same type of criteria, but I think maybe how we try to think about it to to catch it early can maybe be a little bit different. I'd say probably from Especially like the anorexia perspective, I think a lot of boys initially kind of fall more into the category of like, maybe I don't want to be, you know, skinny or lose weight, but like, I want to bulk. I want to have a six pack. I wanna be really good for my sport, but it's like, but what are you doing to have that body? A lot of time it is cutting out a lot of calories, insane exercise. So it's kind of like um more so from the lens of like being Fit versus that whole like, you know, I wanna be skinny, so kind of that mentality is kind of helpful to to flush out with the boys. Um Then will I see anyone 18 to 21 years old? Yeah, so I, um, I have a separate clinic at on the adult side or I work with the adult psychiatric residents, and I will, yeah, I, I see anyone 18 and over. I just had a patient who was 74 years old come in, so, um, there really is no age limit at this point. Anything else? Well, if that's all the questions for today. I wanna thank you so much for your time, Doctor Bishop. It's a very great presentation and you know, it's definitely important for all of us to, to know. So thank you so much, um, and we, um, we hope to have you back sometime soon. Great. Yeah, thank you so much, everyone, and feel free to reach out with any um questions or suggestions of how we can be more helpful. Have a good Friday and then weekend. Thank you, you too. Bye. And for everyone who's still on scanning the QR code, I'm gonna put in the chat for next week what you can expect from early bird rounds. And we'll see you all then. Have a good weekend. Created by Presenters Bridget Galati, DO Assistant Professor, Psychiatry View full profile
